[Feasability of real time contrast enhanced ultrasound in renal disease]. / Etude de faisabilité de l'échographie de contraste en temps réel dans la pathologie rénale.

OBJECTIVES: To evaluate feasibility of real-time contrast enhanced ultrasound in renal disease. MATERIALS AND METHODS: Eighteen patients (sex-ratio=1: mean age 62.3 +/-18.1 years) presenting with several renal diseases were enrolled in the present study. Real time contrast enhanced sonography was performed using an ultrasound dedicated system Esatune (Esaote, Firenze, Italy) with a very low mechanical index (MI<0.1) and a dedicated contrast software CnTI after bolus injection of 2.4 ml Sonovue (Bracco, Milan, Italy). Detection, characterization and extension of renal masses as well as inflammatory and ischemic lesions were evaluated. The results were compared to those obtained by reference method such as contrast-enhanced CT-Scan or MRI. RESULTS: This preliminary study gave some valuable results compared to baseline sonography: marked improvement in tumor delineation or internal microvasculature, detection of venous extension, improvement in cystic mass characterization. Diagnosis confidence was improved and reached 83% when diagnosis concordance with reference modality was improved by 50%. CONCLUSION: These preliminary results show that real-time contrast enhanced sonography could improve detection and characterization of renal masses by a complete assessment or arterial phase. Further studies are required to confirm these first results with possible advantages for the diagnosis of renal affections.

Time-motion reconstruction of mitral leaflet motion from two-dimensional echocardiography in mitral valve prolapse.

To assess the contributions of mitral leaflet billowing and exaggerated systolic mitral anular expansion to posterior motion of mitral leaflets recognized as mitral valve prolapse (MVP) by M-mode echocardiography, time-motion reconstructions of the anteroposterior displacement of points equally spaced along the anterior and posterior mitral leaflets were derived by computer-assisted analysis of 2-dimensional echocardiograms. Late or holosystolic posterior displacement of mitral leaflets, greater than or equal to 2 mm, occurred in the reconstructions from 24 of 24 (100%) patients with MVP with leaflet billowing and in 20 of 24 (83%) patients with MVP without leaflet billowing compared with 4 of 35 (11%) age-sex matched normal adults (both p less than 0.0000002). Posterior motion of the posterior mitral leaflet in time-motion reconstruction was significantly less with respect to the posterior end of the mitral anulus than with respect to the chest wall in patients with nonbillowing MVP (1.6 +/- 1.9 vs 2.7 +/- 1.6, p less than 0.02), but not in those with leaflet billowing (3.6 +/- 1.8 vs 3.9 +/- 1.8, p = not significant), because anular expansion contributed importantly to MVP in the former but not in the latter group. Thus, M-mode echocardiographic patterns of MVP reflect the separate but interacting effects of distinct abnormalities of mitral anular and leaflet dynamics.

Mitral valve dimensions and motion and familial transmission of mitral valve prolapse with and without mitral leaflet billowing.

To test the hypothesis that mitral valve prolapse may be due either to billowing of mitral leaflets into the left atrium or to dynamic expansion of the mitral anulus, mitral leaflet and annular dimensions and motion were measured by computer-assisted two-dimensional echocardiography in 35 normal adults and 48 subjects with auscultatory and M-mode echocardiographic evidence of mitral prolapse. Among normal subjects, mitral leaflet and annular dimensions tended to be larger compared with body size or left ventricular size in women than in men. Mitral leaflet billowing was observed in 24 (50%) of 48 patients with mitral prolapse and 0 of 35 normal subjects (100% specificity). The 24 patients without leaflet billowing had greater systolic expansion of the mitral anulus (p less than 0.0001) than did normal adults or patients with leaflet billowing (41 +/- 14% versus 27 +/- 12% and 22 +/- 11%, respectively) and a significantly lower body mass index (p less than 0.005 versus normal group). The ratio of anterior plus posterior mitral leaflet length to end-systolic annular diameter was lower in patients with prolapse without leaflet billowing than in normal subjects (1.09 +/- 0.12 versus 1.19 +/- 0.15, respectively, p less than 0.01) or patients with leaflet billowing (1.21 +/- 0.17, p less than 0.05). Among 35 relatives with mitral prolapse in the families of 23 patients with prolapse, the pattern was the same as in the proband in 31 (89%) (p less than 0.000002).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of mitral valve dimensions and motion in mitral valve prolapse with severe mitral regurgitation to uncomplicated mitral valve prolapse and to mitral regurgitation without mitral valve prolapse.

To determine the mitral valve abnormalities associated with hemodynamically important mitral regurgitation (MR) among patients with mitral valve prolapse (MVP), computerized 2-dimensional echocardiographic measurements of mitral leaflet and anular dimensions and motion in 26 patients with MVP and MR were compared to those in 48 subjects with uncomplicated MVP, 16 patients with MR due to etiologies other than MVP (rheumatic in 8) and 35 normal adults. Compared to both uncomplicated MVP and normal subjects, patients with MVP plus MR were older (p less than 0.05), had strikingly large mitral leaflets and anulus (p less than 0.0005) and were more likely to have systolic billowing of mitral leaflets in the parasternal long-axis view (24 of 26 [92%] vs 24 of 48 subjects with uncomplicated MVP [50%], p less than 0.001). Overlap in anular and posterior leaflet dimensions in normal and uncomplicated MVP subjects occurred in the 20 MVP plus MR patients who continue to be followed medically but not in the 6 MVP plus MR patients who underwent mitral valve surgery during 22 +/- 14 months follow-up. Patients with MR due to rheumatic or other non-MVP etiologies had enlargement of mitral leaflets and anulus virtually identical to that in MVP plus MR patients. In conclusion, patients with severe MR due to MVP are older, have striking mitral valve enlargement and more frequently exhibit leaflet billowing compared with subjects with uncomplicated MVP. Similar mitral leaflet enlargement was found in patients with non-MVP etiologies of MR, suggesting that mitral anular and leaflet enlargement may play a more general role in the pathogenesis of MR than is currently appreciated.

Two-dimensional echocardiographic imaging: in vitro comparison of conventional and dynamically focused annular array transducers.

Quantitative two-dimensional echocardiography has been adversely affected by a tendency for underestimation of cross-sectional areas of cardiac chambers, a difficulty that might be ameliorated by recent advances in imaging technology. To determine if this were so, we measured echocardiographic cross-sectional areas of 25 formalin-fixed animal left ventricular (LV) sections in vitro using conventional 13 mm and 15 mm diameter fixed-focused single element transducers, and a 15 mm diameter dynamically focused annular array transducer at 3 different distances between myocardial slice and transducer (2 cm, 6 cm and 10 cm) and compared the 2-dimensional echocardiographic areas to the corresponding anatomic cross-sectional areas of the same hearts. LV total and cavity area were measured by computer assisted planimetry of videotaped echo images, performed blinded to the transducer used, and photographed anatomic slices; LV myocardial area was derived by subtraction. Comparison of two-dimensional echocardiographic total, myocardial, and cavity areas with corresponding anatomic measurements showed excellent correlation for each transducer at all depths (r = 0.97 to 0.98 for total area; r = 0.98 to 0.99 for cavity area; r = 0.93 to 0.97 for myocardial area). For total and myocardial cross-sectional areas, the slope of the relation between echographic and anatomic areas did not differ significantly from unity, but for LV cavity area this was achieved only by the dynamically focused transducer. In contrast, the conventional 13 mm transducer significantly underestimated larger LV cavity areas in both the near and middle fields (slopes = 0.90 and 0.91, respectively) and the 15 mm transducer yielded slopes from 0.86 to 0.91 in all fields.(ABSTRACT TRUNCATED AT 250 WORDS)

Intra-aortic balloon pumping in the elderly: percutaneous versus surgical catheter insertion.

The feasibility and safety of percutaneous versus intra-aortic balloon pumping (IABP) in the elderly were evaluated in 45 patients who were over 65 years of age (range 65-79). All the patients required counterpulsation for complicated acute myocardial infarction. IABP insertion was attempted by the surgical technique in 22 patients, while the percutaneous approach was performed in 23. A consistent improvement in the incidence rate of successful insertion was attained with the use of the percutaneous technique as compared with the surgical one (91.3% v 59.1%, P is less than 0.05). Furthermore, no major complication was observed with the percutaneous catheter, while a 9.1% (2/22) incidence rate of serious complications was reported with the surgical technique. Thus, percutaneous IABP substantially decreased the unsuccessful insertions and the risk of severe complications in old patients, despite presumably severe aorto-iliac disease. No specifically age-related technical problem seems, therefore, to limit the applicability of intra-aortic counterpulsation to elderly patients, when percutaneous IABP is employed.

Right ventricular infarction: clinical, hemodynamic, mono- and two-dimensional echocardiographic features.

In a series of 75 patients with transmural acute myocardial infarction, a right to left ventricular filling pressure ratio equal to or greater than 0.65 was assumed to be indicative of associated right ventricular infarction. Eleven (24%) out of 45 patients with infero-posterior myocardial infarction had such hemodynamic evidence of right ventricular infarction (Group A). The remaining 34 patients with infero-posterior myocardial infarction (Group B) and the 30 patients with anterior myocardial infarction did not. Two-dimentional echocardiographic examination performed 5 days after admission in the 62 patients who survived, showed right ventricular free wall asynergy in six out of eight Group A patients: in three of them right ventricular enlargement was present. No patient in Group B inferior infarction or with anterior myocardial infarction had abnormal right ventricular motion or dimensions.

[A case of postinfarction spontaneous angina: physiopathological study of the therapeutic effectiveness of intra-aortic balloon pumping]. / Un caso di angina spontanea post-infartuale: inquadramento fisiopatologico dell'efficacia terapeutica della contropulsazione intra-aortica.

A 46-year-old patient showed spontaneous angina with anterior S-T segment depression 30 hours after an inferior acute myocardial infarction. Myocardial ischemia, which was resistant to drug therapy and induced acute left ventricular failure, was promptly reversed by intra-aortic balloon pumping (IABP). Coronary angiography demonstrated diffuse, severe atherosclerotic disease. Efficacy of IABP in this case of spontaneous angina might be ascribed to an increase of the coronary cross-sectional area in response to the increased intraluminal pressure ("passive vasomotion").